Post on 24-Feb-2016
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W J C O N R A D I ED E P A R T M E N T O F I M A G I N G S C I E N C E S
U N I V E R S I T Y O F T H E F R E E S T A T ES E P T E M B E R 2 0 1 2
CASE STUDY: LYMPHOMA/ GRANULOMATOUS DISEASE
HISTORY
• 12 April 2012• 36 year old female (black)• Referred to Surgery department from private GP
• RVD + on ART since 13/01/2012 (EFV, TDF, Lamivudine)• PTB on treatment since 19/03/2012
• Presents with:• Right neck mass• Started as small lump 2 months ago• Progressing in size• Painful
CLINICAL EXAM
• Large solid mass • Extending from right earlobe to angle of jaw• Not mobile• No bruit• No fluctuance• Smaller lympnodes right cervical area
• PROBLEM LIST:• Enlarging mass in upper cervical region (?lymphoma)
• Plan: Ultrasound then TRUCUT
INCISIONAL BIOPSY
• 19 April 2012• Wedge incision made into mass in posterior triangle of
neck• Skin closed with sub-cuticular monocryl sutures• No complications• Discharged following day
• Plan:• F/U in 2 weeks for results
• 29 May 2012• CT scan
SPACES INVOLVED
Parotid space• Parotid gland; Lympnodes• CN VII; retro-mandibular vein, ECA
Masticator space• Masseter, Pterygoid and temporalis muscle• CN V3; venous plexus and mandible
Parapharyngeal space• Fat, deep cervical lympnodes and paraganglia• Maxillary art• Lingual/inferior alveolar/auriculo-temporal nerve.
DIFFERENTIAL DIAGNOSISSOLID TUMOR
Paro
tid sp
ace • BMT
• Warthin tumor• Schwannoma
• Lymphoma• Parotid Ca
• Mucoepidermoid• Adenoid cystic M
astic
ator
spac
e• Schwannoma• Neurofibroma
• Sarcoma• Lymphoma• SCC from PMS
Para
phar
ynge
al sp
ace
• Neuroma• Paraganglioma
• Lymphoma• SCC of nodes• Metasteses
• systemic
HISTOLOGY RESULTS
• 23 May 2012• Microscopy• Fibro-fatty tissue; muscle and tumor • Atypical cells
• large hyperchromatic nuclei• Scanty eosinophilic cytoplasm• Prominent nuclear polymorphism
• Tumor infiltrate skeletal muscle
• Immuno-histochemical stains• CK/AE13 and MNF116 - Negative (Carcinomas)• CD3 - Negative (T cell origin)• CD20/10 - Positive (B cell origin)• Ki67 - Positive (80%) (Mitotic activity)
DIAGNOSIS:
LARGE B-CELL LYMPHOMA
OUTCOME
• 31 May 2012• (Parotid tumor?)• No infiltration of bone• Cervical and axillary
lympnodes
• PLAN:• Theatre on 07/08/2012• superficial
parotidectomy • cervical dissection
• Missed theatre date!
• September 2012• Mass still enlarging• Tender• Not mobile
• PLAN:• Repeat CT• Surgery on 16/10/2012
REFERENCES
• Harnsberger. Diagnostic Imaging: Head and neck. First edition; 2006. AMIRSYS. Elsevier Saunders.
• Weissleder. Primer of Diagnostic Imaging. Fifth edition; 2011. Elsevier Mosby.
• Robbins and Cotran. Pathological Basis o Disease. Eight Edition. Saunders Elsevier